Addressing asthma self-management: why we need a new approach

Asthma affects 7.5 million people in the UK, and yet it is often misunderstood as a mild, childhood condition. In reality, unmanaged asthma can be fatal, and the UK has one of the highest asthma death rates in Europe. Over half of these deaths are considered preventable through better self-management, but despite the availability of effective treatments, many people with asthma, particularly those with mild to moderate symptoms, continue to die from preventable asthma attacks.

Identifying risky behaviours 

A significant issue lies in adherence to preventive therapies. Many people with asthma, especially those at the highest risk, fail to engage with primary care or adhere to their prescribed medication. Some do not see their asthma as a real threat to their health, leading to dangerous behaviours that worsen their condition. Effective asthma management involves daily use of inhaled corticosteroids (ICS), also known as preventers (typically brown inhalers), alongside bronchodilators (blue inhalers) for breakthrough symptoms. However, overuse of relievers and poor adherence to preventers are common risk factors for asthma attacks.

Current asthma management guidelines recommend recognising symptoms early, taking action (or seeking medical help), adhering to a regular medication routine, and using the correct inhaler technique. However, many people struggle with these behaviours. Evidence shows that asthma self-management relies on specific behaviours—such as regular use of preventers, seeking advice when necessary, and actively monitoring symptoms—that need to be built into daily life.

Mapping asthma self-management behaviours

To better understand the barriers and enablers to these behaviours, we developed a map of asthma management behaviours. This was built using insights from existing patient data and a literature review. Through this process, four key behaviours emerged that significantly impact asthma management: medication adherence, symptom monitoring, support-seeking, and advice-seeking. These behaviours often operate within reinforcing feedback loops, either amplifying or dampening an individual’s actions over time.

Developing distinct personas: 'blue inhaler vs 'brown inhaler'

Our partnership with Public Health England and YouGov led to a survey of 2,324 UK adults with asthma. Statistical analysis identified distinct personas based on adherence behaviour, with a focus on preventer and reliever use, information-seeking, and self-monitoring. For instance, 53% of people reported taking their preventer regularly but overused their reliever. Conversely, 16% took their preventer consistently but only used their reliever in emergencies. I call these two groups, which make up 69% of people we surveyed, ‘brown inhaler’ people. However, 31% of individuals did not take their preventer regularly, independent of reliever use. I call this group ‘blue inhaler’ people.

One such persona is Hawli, who is not engaged in managing her asthma and who typifies the ‘blue inhaler’ personality. She does not visit her GP, refuses to take medication daily, and often seeks information online. She struggles with routine and does not recognise worsening symptoms. She probably only accesses medical treatment via A&E in the middle of the night. For people like Hawli, current guidelines recommending daily use of preventers and consistent symptom monitoring simply aren’t effective, as she does not see asthma as part of her identity or a health threat.

A new approach is needed

This poses an important question: How can we reach the 31% of people with asthma who do not want to manage their condition? They are at a much higher risk for severe attacks or hospital admissions. Is it realistic to expect these individuals to change their behaviour, for a blue inhaler person - likely to be chaotic, disorganised, stressed by routine - to become a brown inhaler person - organised, careful, routine-loving? Perhaps a new approach is needed—one that doesn’t force behaviour change but instead provides tailored solutions, including alternative guidelines, different action plans, and potentially digital support that works with their existing behaviours.

Ultimately, improving asthma management in the UK requires a shift in how we engage people with the condition. By focusing on the barriers to self-management and developing solutions that align with real-world behaviours, we can reduce hospital admissions and improve quality of life for millions living with asthma.

Sharing our resources to build on this work

Asthma + Lung UK have resources available for others wishing to build on this work including an Information Pack (interactive systems map (Figma), patient behaviour journey maps, detailed personas, COM-B tables and empathy maps) and a Design Toolkit (impact mapping tool, journey mapping tool, behavioural challenge statements and intervention evaluation tool). Please contact me at swalker@asthmaandlung.org.uk for more information.